"France's Model Healthcare System"

Paul Dutton on healthcare in France:

France's model healthcare system, by Paul V. Dutton, Commentary, Boston Globe: Many advocates of a universal healthcare system in the United States look to Canada for their model. While the Canadian healthcare system has much to recommend it, there's another model that has been too long neglected. That is the healthcare system in France.

Although the French system faces many challenges, the World Health Organization rated it the best in the world in 2001 because of its universal coverage, responsive healthcare providers, patient and provider freedoms, and the health and longevity of the country's population. The United States ranked 37.

The French system is also not inexpensive. At $3,500 per capita it is one of the most costly in Europe, yet that is still far less than the $6,100 per person in the United States.

An understanding of how France came to its healthcare system would be instructive in any renewed debate in the United States.

That's because the French share Americans' distaste for restrictions on patient choice and they insist on autonomous private practitioners rather than a British-style national health service, which the French dismiss as "socialized medicine." Virtually all physicians in France participate in the nation's public health insurance, Sécurité Sociale.

Their freedoms of diagnosis and therapy are protected in ways that would make their managed-care-controlled US counterparts envious. However, the average American physician earns more than five times the average US wage while the average French physician makes only about two times ... average earnings of ... compatriots. But the lower income of French physicians is allayed by two factors. Practice liability is greatly diminished by a tort-averse legal system, and medical schools, although extremely competitive to enter, are tuition-free. ...

Nor do France's doctors face the high nonmedical personnel payroll expenses that burden American physicians. Sécurité Sociale has created a standardized and speedy system for physician billing and patient reimbursement...

It's not uncommon to visit a French medical office and see no nonmedical personnel. ... No back office army of billing specialists who do daily battle with insurers' arcane and constantly changing rules of payment.

Moreover, in contrast to Canada and Britain, there are no waiting lists for elective procedures and patients need not seek pre-authorizations....

How might the French case inform the US debate over healthcare reform? National health insurance in France stands upon two grand historical bargains -- the first with doctors and a second with insurers.

Doctors only agreed to participate ... if the law protected a patient's choice of practitioner and guaranteed physicians' control over medical decision-making. Given their current frustrations, America's doctors might finally be convinced to throw their support behind universal health insurance if it protected their professional judgment and created a sane system of billing and reimbursement.

French legislators also overcame insurance industry resistance by permitting the nation's already existing insurers to administer its new healthcare funds. Private health insurers are ... central to the system...

The French system strongly discourages the kind of experience rating that occurs in the United States, making it more difficult for insurers to deny coverage for preexisting conditions or to those who are not in good health. ...

Like all healthcare systems, the French confront ongoing problems. Today French reformers' number one priority is to move health insurance financing away from payroll and wage levies because they hamper employers' willingness to hire. Instead, France is turning toward broad taxes on earned and unearned income alike to pay for healthcare. ...

Perhaps it's time for us to take a closer look at French ideas about healthcare reform. They could become an import far less "foreign" and "unfriendly" than many here might initially imagine.

Comments

[ken melvin]

Objectivity. What a novel idea.

[evagrius]

But think about the doctors...facing lower income?

[ppgl]

Canada? France? Wonder what RUDY would say? Oh yea - Socialism. Well? Maybe a little "socialism" would be better than the current US mess.

[anne]

"But think about the doctors...facing lower income?"

Huh??? Possibly a joke, but frightening doctors would be a foolish mistake.

[anne]

Rudy Giuliani has a typical "if you are only as strong willed you will never ever need health care" approach to health insurance. So, all we need are incentives to stay as healthy as I am and there we have a you buy your own cheap health care insurance plan.

[Dave M.]

BusinessWeek magazine says that all is not that rosy in France's healthcare system....

http://www.businessweek.com/magazine/content/07_28/b4042070.htm

""In 1990, 7% of health-care expenditures were financed out of general revenue taxes, and the rest came from mandatory payroll taxes. By 2003, the general revenue figure had grown to 40%, and it's still not enough. The French national insurance system has been running constant deficits since 1985 and has ballooned to $13.5 billion.""

""That $55,000 equals the average yearly net income for French doctors, a third of what their American counterparts earn. Then again, the French government pays two-thirds of the social security tax for most French physicians—a tax that's typically 40% of income.""

""Specialists who have spent at least four years practicing in a hospital are free to charge what they want, and some charge upwards of $675 for a single consultation.""

[Farrar Richardson]

Good article, but not quite accurate.

"French legislators also overcame insurance industry resistance by permitting the nation's already existing insurers to administer its new healthcare funds. Private health insurers are ... central to the system..."

In fact, private and mutualist insurance companies are only peripheral in the system.

Health insurance for salaried workers - most of the insured - are administered entirely by the govt run Securité Sociale. Only the self employed have their own systems set up on a mutual basis, and these are required to pattern their reimbursement systems after the govt core system.

In fact I don't know how the efficient centralized reimbursement system could have been set up if it had not been managed by the govt. Another argument for a single payer plan, or at least a centralized billing and reimbursement system.

There is some room for private and mutual companies, who run the complementary plans. As I explained once before, the core plan covers only about 65 % of ordinary outpatient care, except for the poor whoo are covered at close to 100%. Optional complementary plans cover the rest. Securite Sociale has set up data exchange with the complementary insurers, which makes their billing and reimbursement automatic as well.

Major surgery and serious illness are covered at nearly 100% for everyone.

[dale]

Aside from the toll the health insurance industry takes from the US health dollar, and the refusal of our government to negotiate Rx prices with big pharma, the proportionally higher incomes of US MDs does seem an important piece of the puzzle of why we pay so much more for health care than other wealthy nations.

Although I've read that much of this differential is due to the higher incomes of the US specialist, not the general practitioner.

So- as we try to build a national-wide coalition for universal single payer health care system- do we look for ways to transfer some of that high US MD income into health care savings? At the risk of alienating MDs from the coalition?

Jonathan Cohn, in his book, Sick, published last spring, also makes a strong case for the superiority of the French system as a model for the US to emulate.

[Farrar Richardson]

Dave

Almost correct, Business Week -

""In 1990, 7% of health-care expenditures were financed out of general revenue taxes, and the rest came from mandatory payroll taxes. By 2003, the general revenue figure had grown to 40%, and it's still not enough. The French national insurance system has been running constant deficits since 1985 and has ballooned to $13.5 billion.""

The 40% does not exactly come out of the general pot, but out of a general flat tax on income to catch retired people, rentiers, and people like me with foreign income. Since everyone is covered, putting everything on a payroll tax would not be fair.

Although, they have lower expenses, I would agree that French GP's are not paid enough.

The specialists I see charge max 40 Euros per visit, although some prestigious Drs go considerably higher, but the fees you mention are a rare exception.

There are other problems, too, such as a shortage of nurses, due to their low pay.

Whatever we do med care is going to get more and more expensive for the French and just about everyone. The questions are - Who pays? and Who makes outlndish profits?

With all its problems, I can't think of a better system

Whatever we do

[anne]

Farrar Richardson, thank you for the continuing important descriptions and explanations. I agree that health care costs will increase relative to national income, but that does not bother me in the least since the possibilities of biological and related health care advance are so valuable.

Remember to pay attention to drug cost issues in France, as I am doing here.

[Nate]

Does anyone know what all is included when the WHO calculates the cost per capita?
Namely, do they include indirect subsidies like those for med school, government R&D expenditure subsidies, etc. that vary from country to country and greatly effect other outcomes, such as labor wages and drug costs.
For example, if you don't count government subsidies for Med school, you would need to mark up the per capita health care spending of countries like France that much more heavily subsidize Med school than the US does to get an apples to apples comparison in that regards.

[anne]

"For example, if you don't count government subsidies for Med school, you would need to mark up the per capita health care spending of countries like France that much more heavily subsidize Med school than the US does to get an apples to apples comparison in that regards."

So, we could lower American health care costs by ending free public schooling entirely, and raising public college and university costs to, say, Stanford's with no grants allowed.

[anne]

"Namely, do they include indirect subsidies like those for med school, government R&D expenditure subsidies, etc. that vary from country to country and greatly effect other outcomes, such as labor wages and drug costs."

As with the Business Week article, is the idea to show that any suggested change in the American health care system will prove self-defeating no matter how troublesome the system may prove. I continue to hear even public radio commentators refer to Michael Moore as a propagandist, so immediately discounting any possible idea Moore might have presented on health care.

[cm]

evagrius: "doctors facing lower incomes"

Two words -- "bidding position".

[anne]

Doctors are decidedly not facing lower incomes as such, although administrative costs can be nightmarish and doctors would surely benefit from lowering such costs. There are all sorts of shortages of doctors, and well organized doctors have nothing whatsoever to fear from health care administrative reforms along French lines. There is also every reason to offer minimsl tuition public college and university-professional school education along the European lines.

[evagrius]

But doctors should have lower incomes. And health workers higher.
Lawyers should have lower income and para-professionals higher.

What's the fixation on doctors and lawyers having such high incomes?

Not all doctors have high incomes. Those in public health have a low one in comparison to private doctors and they face situations far more serious and challenging.

If doctors oppose health care reform on the basis of a possible lower income, then they are not doctors but health mercenaries.

[Brian]

All of your comments are very interesting. There certainly seems to be a movement toward socialized medicine. I have a few serious questions for you all. What will you do when the government decides you make too much? What if tomorrow the federal government decided that all accountants, engineers, and managers make too much money? The reason would be the same as above, its for the children and the common good to lower the pay. If it were you, I imagine you would have an outcry. I just don't see the role of the government to decide who makes too much money. What if the government decides to take over your career? How would that make you feel? For goodness sake don't put the government in the middle of this. For those of you that want to see a failed government run healthcare system, look at Tenncare which failed in the state of Tennessee. It was bascially the same plan as Hillarycare of the early 90s fame.

I do work in healthcare and absolutely can tell you that a French solution is not going to work for 300 million people in the United States. We instead need an American solution.

[anne]

"There certainly seems to be a movement toward socialized medicine."

Immediately the discussion is over. Between supposed health care reformers beginning with lower doctor incomes, which is nonsense, and moving to "Oh yea - Socialism" discussion could only last a short while until the real working in health care opposition came along with nonsense about "socialized medicine" and craziness about Tenncare or Tennessee Medicaid having anything to do with Hillarycare or decent health care in general.

[Adam]

Are there any unnecessary limitations to the number of doctors in the US? They must all get into medical school, right, but there must be quite a demand. Can doctors with non US degrees practice here? Just curious if any of you knew.

[anne]

So, there we have the craziness of watching Tennessee cut health care insurance for those who are already eligible for government insurance and finding the resultant health problems as increasing infant mortality and somehow this is likened to any sane health care reforms especially the sort of reforms that could, say, work. How about Mississippi care, then? How about socialized, doctor smashing, Mississippi-Hillary care * health insurance reform, then?

* Not available for accountants, engineers, managers or lawyers.

[anne]

International doctors who pass American exams and complete a residency can practice here, and large numbers of doctors here, residents and on, were born abroad. Also, American students can and do go to medical school in other countries and return to exams and residency and practice.

[anne]

Interestingly, though we strictly limit travel to Cuba, we allow American students to go to medical school in Cuba which happens to be free. When the Administration threatened the Cuba study allowance, even a Republican Congress refused to keep students from the program.

[ken melvin]

I suggest we look to Tennessee in all matters.

[Farrar Richardson]

What is this crap about subsidized education? In an economy of plenty, why shouldn't university tuition be free or nearly so to anyone with the talent and determination to pursue it as far as (s)he wants. Wouldn't that benefit the whole society?

What is this further crap about socialized medicine. In an economy of plenty, doesn't equal opportunity also mean equal access to health for all?

Why are so many still thinking 18th and 19th century?

[Farrar Richardson]

The question, of course is how do we get there from here.

[ken melvin]

Farrar, 'tis far far better to keep doing things wrong and hoping they come out right. A measure of our faith. Speaking of which, I know of nations that have held on to failing policies for decades and decades in the face of evident better ones. As you've no doubt noticed, ignorance is best adorned with a wreath of pride.

[Lafayette]

DM: "In 1990, 7% of health-care expenditures were financed out of general revenue taxes, and the rest came from mandatory payroll taxes."

True, but in the rest coming from payroll "contributions" (not taxes in France), there are two components, one the employee and the other the company.

So, the above number of 7% is way off - general revenue taxes or employee contributions via payrolls ... what's the difference?

And, finally, whether it comes out of the payroll or not is irrelevant. Companies recuperate their Health Care contributions in the pricing of their products and services. We, as consumers, therefore pay for Health Care (amongst other public services) anyway.

There's no free lunch - so don't believe that there is a difference if Health Care financing comes from the government or payroll taxes - because there isn't. The only difference is the manner in which Health Care is administrated.

In fact, in France it is the GP who decides whether or not and the kind of health care that the recipient needs, not some nerd in an insurance company. If the doctor is found to prescribe too much "brand name" medicine, instead of generic brands, s/he gets their knuckles rapped (with a penalty).

If they push to much work towards services in which they have a financial interest (external radiology examinations, testing services), then they find themselves answering to a state prosecutor.

When "controls" are enforced, doctors generally stay in line. But, the largest difference -- by far -- is the article's mention of tort law. France's courts are not great on stupendous tort damages accorded to claimants.

[Laurent GUERBY]

For french doctor training fr.wikipedia has a detailed description of the 9 to 11 years of training of doctors:

http://fr.wikipedia.org/wiki/%C3%89tudes_de_m%C3%A9decine_en_France

Year 1 is selection year, 10-15% passing rate on theory stuff. Starting year 3 or 4, students are paid a small sum per month (100-250 euros, but with full health and retirement benefits) and work in hospitals. At year 7 they are allowed to do presciption on their own (still monitored though) and earn "normal" wages.

Of course student have to pay housing, etc... government budget financial help depending on ressources for all students including medecine student.

All in all, since medecine students start doing useful work quickly and before that it's all theory (not really expensive) I doubt training could explain the difference. France trains around 5000 doctors per year, I really doubt the cost is substantial.

Doctors are very respected in France from a social standpoint. Since you choose your own doctor (for common illness, otherwise it's hospital) their peopleware skills are usually highly developped (in short: excepted for your illness, it's pleasant to see a doctor :). Of course they earn less than in other countries but recent government have raised doctor fees by quite a lot.

As noted, paperwork is inexistant, most doctor shop are doctor only with no employee, all is computerized and payment/registering takes a few seconds (even without computers the filling was really minimal).

600 euros is really exceptional, even in Paris good specialist doctors cost 50-60 euros a visit. If you really want to "pay" less (if your supplementary private health insurance is inexistant or doesn't cover overcharge), government lists doctors that apply no supplementary charge near your home.

As last resort you can always walk in a hospital and get treated (less "friendly" but as efficient).

Payment equilibrium for Securité Sociale is not hard to reach, it's just that politician delay the necessary (not that high) tax raises by papering over silly small scale "reforms".

Overall, there is nothing extraordinary about the french system, government run the backend of the system (salary tax, payments), negociate drug prices country-wide, regulate minimum visit price and maintain big hospitals. Citizens choose their doctors and drug sellers, wether to pay or not for private insurance covering the extra costs in some case (notably dental prothese, optics and overcharging doctors). Private insurance companies can be not for profit "mutuelles" or for profit companies, your choice.

Of course starting for the completely corrupt and ultra inefficient USA situation it will be hard to go anywhere, good luck anyway!

[realpc]

"Practice liability is greatly diminished by a tort-averse legal system,"

None of the Democratic candidates will ever recommend this, certainly not Edwards. But malpractice insurance is a major reason why American MDs have to charge so much. They can easily pay $100k or more in malpractice insurance.

John Edwards took advantage of the fact that a newborn's life has maximum value legally, and also that there are so many things obstetricians can be blamed for.

The answer is not to mindlessly raise taxes and pour ever more money into the central government. What about limiting malpractice awards?

[robertdfeinman]

A recent study (sorry I don't have the link at hand) found that only 20% of health care expenses in the US go to doctors.

Everyone likes to point to doctor's salaries as being too high, but these are highly skilled people with many many years of training. Some punk kid can graduate law school and start at a Wall Street firm at $140,000. Why isn't anyone complaining about that. How about the heads of the insurance companies? Several have packages worth over $1 billion. How many doctor's salaries would that pay?

[SanFranciscoJim]

For one thing, plenty of people, here and elsewhere, have complained about the widening wage and wealth gap.

But no one on Wall Street routinely bills the State for their services and expects taxpayers to pick up the tab, the way MDs do with Medicare payments.

[Sonia]

Uwe Reinhardt says 10% of health expenditures are directly attributible to physican wages. His point is that cutting physican pay will disuade the most capable students from a career in medicine since these students would see their potential pay shrink relative to the large rewards in law and finance. A rebutal on healthcareblog points out that (1) physcians in Western Europe also compare careers with high paying careers in finance and law and (2) that there are only a few very high paying jobs in finance and law and that only a very small number of Wall Street types make the really big bucks. I add that the differences between e.g. $300 million and $600,000 or $300 million and $400,000 are almost identical. If physician pay differences (per capita) do not account for a major difference in cost of then we need to look elsewhere for the difference in cost. End of life care is one place to look.

[cm]

SF Jim: Look beyond the surface. For one thing, doctors are not (generally) "billing the state". As for accountants, lawyers, financiers, and other intermediaries, they can pull their rates/salaries because society and economy are set up such that in the aggregate they have a gatekeeper function -- you cannot, at least practically, evade their services.

I don't mean to insinuate that said intermediaries are useless, don't provide a tangible service, or make their money by extortion and holdup, but when circumstances drive everybody into your office it's so much easier to "negotiate" prices.

The same thing is of course true for medical practitioners. But it's not a matter of billing the public hand.

[anne]

"But no one on Wall Street routinely bills the State for their services and expects taxpayers to pick up the tab, the way MDs do with Medicare payments."

Ah, then there will be no more Medicare, no more Medicaid, ans especially no more Veterans Health Care. No more billing the government anymore never ever for the cost of caring for a soldier. Imagine the nerve of doctors, expecting to be paid for like doctoring.

[Lafayette]

LG: Since you choose your own doctor (for common illness, otherwise it's hospital) their peopleware skills are usually highly developped (in short: excepted for your illness, it's pleasant to see a doctor

Thank you for an excellent review of French medical training. I think you could add that medical assistants also follow a similar "fast track" route to operational efficiency.

I would only make one more comment: When you go to a doctor here in France, the onus is on "doing something". Frankly, I suspect that a great many maladies are fictitious or prompted by nervous stress. (There must be a basic reason why Americans and French are the biggest pill-poppers on earth.)

So, doctors WILL proscribe something, even if the malady may be psychosomatic resulting from depression or other disorders of a transitory nature. The effort here, therefore, is to incite them to prescribe generic drugs at considerable discounts to their brand name counterparts. Perhaps "self medication" of some of these cases would help avoid the fee necessary to see the doctor? For the moment, health policy in France rests upon the notion that "the doctor knows best".

There are side effects, however. Many people think that if they are not prescribed an antibiotic that they "have not been adequately treated". So, the prescription of antibiotics has led to cases where they are no longer effective since the viruses have learned immunity.

More so, the "collateral damage" of a potent antibiotic degrades indigenous defenses against some germs, microbes and viruses ... so do we really end up better off?

America must make an effort to get the cost of medical training (for doctors, nurses and aids) down to a reasonable level. The remedy is perhaps even more drastic. If the state were assuring health care, it could mandate health care prices (fees, pharmaceutical prices) and thereby assure that generally good health care should be affordable at a more reasonable cost to the nation.

But, isn't that "socialized medicine"? Horrors! The return of Godzilla!

You betcha, it IS a Public Service. But, so is secondary school education, the police, justice and firemen as well as defense of the nation. So .... why not Health Care, which is a concern of all citizens?

In general, we should not tinker with market mechanisms ... except when they don't work. Health Care in America is proven not to work for 100% of the population, which should be the minimum standard.

The rest of the developed world has proven that it leaves far fewer people behind than the American version of private medicine.

[Lafayette]

anne: Imagine the nerve of doctors, expecting to be paid for like doctoring.

That is NOT the issue, which is clearly an exaggeration - about as much as the horrendous fees that doctors are paid in America.

Let's not make the mistake that the "bleeding hearts" would have us do -- that medicine must be free, gratis and for nothing; regardless of the context. Yes, it should be paid for by the public purse (meaning our taxes), but it must be administrated as well with firm hand on cost control.

[Lafayette]

Sonia: If physician pay differences (per capita) do not account for a major difference in cost of then we need to look elsewhere for the difference in cost.

And I suggest that Renhardt has got it wrong.

Here is a better idea of where Health Care costs come from. The following is excerpted from the study (done in California):
7.1% - Adminstration
9.0% - Nursing Home and Home health care
10.2% - Other (Miscellaneous)
10.3% - Dental & Other professional
10.7% - Prescription Drugs
22.7% - Physician and Clinical Services
30.7% - Hospital Care

That salaries are less than 10% of the above is unadulterated nonsense.

In the very last item, "Hospital Care", take out operational costs (real estate and running expenses) and add what remains to the 22.7% of "Physician and Clinical services" as well as "Dental & Other professional" - and the total is closer to 50%, if not more.

NB: Whilst at it, do the same manipulation for "Nursing Home and Home health care" ...

[anne]

Lafayette, please set down the precise cost reference or references when possible.

[Fr.]

Here are a few comments on some of the approximations in the Boston Globe column:

http://bookofsaturday.blogspot.com/2007/08/healthcare-systems-compared-on-paul.html

Farrar: as you have noted yourself, complementary insurers/mutuals cover a third of health care refunds -- I think this fits the "central role" qualificative assigned by Dutton.

[Laurent GUERBY]

Lafayette, I just translated part of the wikipedia article so thank wikipedia authors :).

While the "malade imaginaire" is not new (Moliere, 1673 :) I don't know if the cost is something to go after. Another factor in prescription growth is the corrupting power of the drug industry over doctors that ultimately comes from the corrupted intellectual property regime. A simple solution would be to get rid of IP, real free-traders, small state and libertarians will support me here :). I would weight the cost of this second effect well above the malade imaginaire but I have no data to back this up. And I'd also guess this second cost is way higher in the USA than in France.

The french government has been running a campaign against automatic use of antibiotics (that don't work against viruses BTW that's the technical point :) which seems to be successful on doctors and patients. Web site here:

http://www.antibiotiquespasautomatique.com/

So this one should be on its way to history manual :).

On a more general note, for human basic needs like housing, energy, transporation and health I think that if you compare various country systems performance the market-or-death camp fares quite badly against the state-organized camp.

[USA ICU MD]

What is the healthcare crisis? In the US it is the free care given to wealthy old people that is the crisis? Also the fact that 70% of your total dollars spent over your lifetime are spent in the last 30 days of your life. In france terminal care and death are not viewed as defeats. The 80 year old with a lung mass is not even told they have cancer. They are told that they will try an antibiotic and will be kept comfortable. None of the nonsense. Ct, MRI, Pet scans, VATS, chemo, radiation and then death. These are social, cultural issues. The solution is simple. Do less to more people. You are old and you will die. Sorry but that is life....

[Terry]

Does anyone know what the work load for French doctors is compared to American doctors? I have been under the impression that everyone has more leisure time in France, including physicians.

It's not all about the money, and I wish that people would include this concept in the discussion. In America we are too materialistic, in my opinion. There is more to life than huge incomes, luxury SUVs and ostentatious homes.

I have also heard that doctors in France still make house calls. Not having to leave the house if you're sick. What a concept.

Just don't get sick in France in August, because everyone, including doctors and dentists, takes their vacation at the same time. But nothing is perfect.

The French system is still the better system, and benefits the vast majority of citizens. There really is no question about it. I just don't see Americans changing course in that direction. More likely the French will succumb to the temptation of moving toward the American way, especially under their new leadership. This will be unfortunate for the French people.

[anne]

Terry:

"I have also heard that doctors in France still make house calls. Not having to leave the house if you're sick. What a concept."

So too, French ambulance aid includes a physician. But, imitation is not the point rather the need to learn from other approaches. Not only are we a country in which tens of millions of workers have no health care insurance but a country in which tens of millions of workers have not an allowance for a single paid sick day in a year. No other developed country can match that. Vacation days? Oh well.

[Lafayette]

anne: Lafayette, please set down the precise cost reference or references when possible.

The source is linked, the data presented as in the source.

What more, exactly, must I do for the numbers to be understood? Their interpretation is for each of us to present and debate.

[anne]

http://www.nytimes.com/2007/08/05/opinion/l05doctors.html

What Doctors Make, and Why

To the Editor:

In "Sending Back the Doctor's Bill," you compare the incomes of American physicians with those earned by doctors in other countries and suggest that American doctors seem overpaid. A more relevant benchmark, however, would seem to be the earnings of the American talent pool from which American doctors must be recruited.

Any college graduate bright enough to get into medical school surely would be able to get a high-paying job on Wall Street. The obverse is not necessarily true. Against that benchmark, every American doctor can be said to be sorely underpaid.

Besides, cutting doctors' take-home pay would not really solve the American cost crisis. The total amount Americans pay their physicians collectively represents only about 20 percent of total national health spending. Of this total, close to half is absorbed by the physicians' practice expenses, including malpractice premiums, but excluding the amortization of college and medical-school debt.

This makes the physicians' collective take-home pay only about 10 percent of total national health spending. If we somehow managed to cut that take-home pay by, say, 20 percent, we would reduce total national health spending by only 2 percent, in return for a wholly demoralized medical profession to which we so often look to save our lives. It strikes me as a poor strategy.

Physicians are the central decision makers in health care. A superior strategy might be to pay them very well for helping us reduce unwarranted health spending elsewhere.

Uwe E. Reinhardt
Princeton, N.J., July 30, 2007
The writer is a professor of political economy at Princeton University.

[anne]

A specific reference is a specific reference, and I found only an outline and am not about to search blindly, though a quick search of California HealthCare Foundation to find the express reference turned up nothing.

Thanks, by the way, for the crude nasty writing. Looking forward to more. Duh.

[anne]

http://www.nytimes.com/2007/07/29/weekinreview/29berenson.html?hp

July 29, 2007

Sending Back the Doctor's Bill
By ALEX BERENSON

HOW to fix the health care system?

Easy, liberals say. If Washington would just force cuts in prescription drug prices and insurance company profits, plenty of money would be left over to cover the uninsured.

Conservatives prefer to argue that the answer lies in forcing people to pay more of their own medical costs.

But many health care economists say both sides are wrong. These economists, some of whom are also doctors, say the partisan fight over insurers and drug makers is a distraction from a bigger problem: the relatively high salaries paid to American doctors, and even more importantly, the way they are compensated.

"I always find it ironic that when I go to doctor groups and such, they always talk about the cost of prescription drugs," said Dana Goldman, director of health economics at the RAND Corporation, a nonprofit research institute in Santa Monica, Calif.

Prescription drugs cost, on average, 30 percent to 50 percent more in the United States than in Europe. But the difference in doctors' salaries is far larger, Dr. Goldman said.

Doctors in the United States earn two to three times as much as they do in other industrialized countries. Surveys by medical-practice management groups show that American doctors make an average of $200,000 to $300,000 a year. Primary care doctors and pediatricians make less, between $125,000 and $200,000, but in specialties like radiology, physicians can take home $400,000 or more.

In Europe, however, doctors made $60,000 to $120,000 in 2002, according to a survey sponsored by the British government in 2004.

Given the years of training that doctors require and the stress and importance of their jobs, few would disagree that they should be well paid. In addition, with a year of medical school now about $30,000, many doctors leave school deeply in debt. And many doctors would argue that cutting salaries would only persuade talented, college graduates to pursue better-paying professions.

Still, the lower salaries are a significant part of the reason that European countries spend less on health care than the United States does — a fact liberals avoid mentioning when they preach the advantages of a European-style single-payer system.

Americans generally do not seem to mind the fact that doctors are well paid. In public opinion surveys, doctors usually rank as the most trusted professionals. Congress has repeatedly blocked Medicare's efforts to reduce the amount it pays for each procedure doctors perform, even though overall Medicare payments to doctors are soaring and the cuts are legally required to keep the program's budget balanced.

The way that doctors are paid may be an even more significant factor driving up costs and may lead to unnecessary care, said Dr. Peter B. Bach, a pulmonary physician at Memorial Sloan-Kettering Cancer Center and a former senior adviser to Medicare and Medicaid.

In the United States, nearly all doctors are paid piecemeal, for each test or procedure they perform, rather than a flat salary. As a result, physicians have financial incentives to perform procedures that further drive up overall health care spending.

Doctors are paid little for routine examinations and very little for "cognitive services," such as researching different treatment options or offering advice to help patients get better without treatment.

"I don't have a view on whether doctors take home too much money or not enough money," Dr. Bach said. "The problem is the way they earn their money. They have to do stuff. They have to do procedures." ...

[anne]

"What is the healthcare crisis? In the US it is the free care given to wealthy old people that is the crisis?"

Always idiocy....

[anne]

Again, we are merrily spending our way along on an insanely tragic war and occupation in Iraq. A $2 trillion unnecessary fiasco, and the worry is whether we can afford to care for the health of others, never for our health because that is always considerable affordable, but whether we can afford the health of others we can as little about as possible.

War and occupation, fine. Health care, resolved, "let 'em die."

[cm]

From the article quoted by anne: "Any college graduate bright enough to get into medical school surely would be able to get a high-paying job on Wall Street. The obverse is not necessarily true. Against that benchmark, every American doctor can be said to be sorely underpaid."

That's BS. Any occupation "generates" only so much regional or national demand. You are not hired into high-paying positions just because you are smart enough or have certain degrees; businesses "manage" their workforces, employed or contracted, and their costs. Conversely, in a higher-supply situation, job security will decline as fresh and hungry contenders are knocking on the door.

This phenomenon is only temporarily suspended when an industry is growing at a pace larger than the growth of its worker pool, one recent visible example being the dotcom era.

[Farrar Richardson]

Fr

Your URL returned a "not found."

Believe me, the complementaries just tag along. The securité sociale makes all the rules, sets reimbursements, developed the payment system, etc.

Besides cancer, diabetes and other serious illneses are covered at nearly 100% by securité sociale

As are poor people

Also a high percentage of surgery and hospitalisation over two weeks

For the complementaries, this leaves ordinary outpatient care for people above the poverty line. For years, I did without this complementary insurance, but now I'm getting old and worry more.

Of course, this does leave the ins cos less room to complain, especially since they have almost no work to do with complementary med insurance.

[Farrar Richardson]

Fr

Found your blog after retyping the URL.

The comments in your blog seem fair, but note that CMU (universal coverage) is intended only for the poor, and I do not believe access is that difficult. At least I have not heard any complaints.

FR

[Lafayette]

"Any college graduate bright enough to get into medical school surely would be able to get a high-paying job on Wall Street. The obverse is not necessarily true. Against that benchmark, every American doctor can be said to be sorely underpaid."

Bollocks. Under such a supposition, "any college graduate" can do "anything" and become a multimillionaire.

The fair pay of an individual is NOT a matter of "make all you can" just because a market mechanism is defective at finding a fair price equilibrium for services (of any nature).

The private market for health care services is warped and in such markets those who demand such services can expect the government to step in a rectify the imbalance. By mandating prices, if necessary. By increasing the pool of service providors, if possible. (Meaning the importation of qualified staff from abroad.)

The price of health care services, which is concentrated mostly in salaries, is due to the manner in which the practitioners are trained. These costs, from medical schools nationwide, are too expensive. So, of course, medical students expect to have a return on their "investment".

Why not therefore create a program by which the government "recruits" candidates for medical school and pays their expenses throughout -- against a certain period of time during which the graduates work at state-funded hospitals at a decent salary? This creates a parallel health care service for those who cannot afford the expensive version provided by private insurers.

This method is not innovative. It is employed in many countries around the world. Private medicine must compete with state-funded health care and practitioners can chose which they prefer to work in. Many particularly brilliant doctors chose private-practice medicine and make handsome salaries in line with those in the US.

State subventioned medicine is not used in America because of a knee-jerk reaction to "socialized medicine" by politicians in power - a sentiment fomented and defended viciously by a powerful lobby in Washington that funds politicians. (Cut the umbilical cord between politics and vested-interest money and this will end.)

Good health care at decent prices for all should not cost an arm and a leg. That's insane.

[Lafayette]

"In the United States, nearly all doctors are paid piecemeal, for each test or procedure they perform, rather than a flat salary. As a result, physicians have financial incentives to perform procedures that further drive up overall health care spending."

Well, of course. Those "procedures" are effected by whom, if not other health care practitioners. Their salaries are also over the moon.

The whole profession is a racket promoted by high prices because the service providers are insufficient in number to meet the demand.

Increase the number of service providers is the solution and there are a number of ways to do it. The most immediate is recruiting foreign talent. (Polish doctors are recruited by the National Health Service in the UK. The French recruit Moroccan doctors. Etc., etc., etc.)

A longer term solution is for the government to promote the training of health care specialists/professionals (as explained above in another post).

This is NOT rocket science. What is happening in American health care is adequately described by EC101 supply/demand theory.

The market equilibrium is out of whack. So, fix it.

[Tom W]

"So, we could lower American health care costs by ending free public schooling entirely, and raising public college and university costs to, say, Stanford's with no grants allowed."

Anne, your sarcastic post doesn't make any sense. I think you misunderstood what the poster was claiming. He claimed that state-paid tuition is a cost of medical care which might not have been included in the French statistics. His claim doesn't imply that medical care would be cheaper if med school were privately financed.

[anne]

Yes; I understand perfectly, the terrible
French have the terrible nerve to have like free college and university education for like students, and if we were to include the like free education of the terrible French why the French would have like American health care costs like and the French too might move to being like 42 among nations in terms of like longevity like America.

[anne]

Now, what we could do among other things would be to make public college and university schooling here as inexpensive as in France. But, that will not do so we must give over insuring the health care of the uninsured because the French cheat by offering students free schooling which makes French health care as expensive as American health care even though we have no free schooling and tens of millions of uninsured. I understand.

[John]

What makes you people believe you can control physician pay? All that will happen if you lower medicare payments is that more people will limit medicare/medicaid (as they are already doing) patients or cut medicare patients out of their practice. In fact, I can't wait until medicare collapses or the payments decrease even more.

[Lafayette]

John: What makes you people believe you can control physician pay?

The same mechanism that "controls" federal worker pay.

The proposition of a parallel health care Public Service does not "control" the revenues of HC-practitioners. It just puts them on a scale that is consonant with the Public Service offering nationally - that is on the same pay scale.

Who controls the pay of firemen, the police, judges, school teachers, air traffic controllers? So, why not those providing Health Care. A parallel Public Service mechanism for providing Health Care to all is the ONLY way to get the outrageous cost of American Health Care back down to reasonable levels. (And, yes, it competes with the present private-insurance managed scheme today that is not sufficiently effective.)

Unless you have a way of doing it with smoke and mirrors. Do tell us how ...

Better yet, patent it. You'll become an overnight millionaire.

[Lafayette]

TW: He claimed that state-paid tuition is a cost of medical care which might not have been included in the French statistics.

Bollocks. And National Defense, is that a "cost of health care"? Of course not. After all, do we want al Qaeda blowing up our universities?

The poster in question is confusing the two, schooling/training and health care. BOTH ARE PUBLIC SERVICES in France. Unlike the US, where only state universities are administrated by the states ... and these latter are far from being "free, gratis and for nothing".

I maintain that by the proper use of "free education", then we can address the lack and shortage of skills that is making American uncompetitive and contributing to its awful income inequality. The uncompetitiveness of health care has long since been the case. (I repeat, a private insurance health care mechanism simply recuperates its costs from corporations - who recuperate the cost from their pricing of products/services. THE CONSUMER PAYS ULTIMATELY, meaning you and me.)

A Public Health care system will be financed out of the public purse, just like the DoD. So, it is financed out of Federal/state revenues, i.e., largely based upon income tax. (And another reason to increase marginal rates on the rich and filthy-rich.) Meaning you and me, the taxpayers.

And why not? Please, someone, explain WHY NOT? Enough of this gibberish. Where is the argument AGAINST a public service health care? Where?

Nowhere to be seen ... so I think I will go ask the AMA.

[John]

Just because people who want universal healthcare yell really loud doesn't mean that the majority of people want universal healthcare. In fact, universal healthcare will not work in our country because 85 percent of the population is covered. They will not want to give up their plan. People do not believe that magically adding 40 million people into the system is going to make their healthcare magically better or cheaper.

[John]

we definately need a stronger safety net for the poor and people with preexisting conditions when it comes to healthcare...

[anne]

"In fact, I can't wait until Medicare collapses or the payments decrease even more."

Interesting the moral meanness that it takes to write such a line. Of course, neither will occur however much any such person can't in fact wait.

[John]

"Interesting the moral meanness that it takes to write such a line. Of course, neither will occur however much any such person can't in fact wait."

Well, I guess your sarcasm detector isn't working very well or maybe sarcasm just doesn't come across on computers. All I'm saying is that the government needs to start funding the programs it has appropriately at this moment before it can start to think about expanding programs. Or else the system WILL collapse.

[anne]

Ah, thank you so much for explaining, John. I do apologize for not reading with more care as though the 3 comments were 1. Reading again, your points all are sensible. I am, by the way, much interested in increasing study in biology and in medicine, and would do so by dramatically reducing the costs of public college and graduate school education. That was nice of you to explain.

[dale]

It's not magically adding the uninsured that will lower costs- it's doing so in such a way that rationalizes our health insurance system in similar ways as our European friends. They cover everyone- not just the lucky 85%. They get just as good, if not better, health outcomes. They do it for half of what we spend. Let's not fool ourselves into thinking that we cannot learn from others who have found better ways- both morally and fiscally- to deliver health care. Instead of reacting in fear or insisting that we are somehow unique- let's look at how they manage their systems with an eye towards learning and growing as a nation.

[John]

First, let me say that I think we should strengthen our safety nets for the poor and those with pre existing conditions. I am against turning the whole system over to the government though. I believe a problem is that the statistics people quote are misleading. The two most commonly sited statistics of infant mortality and life expectancy are flawed.

Example 1:
infant mortality is a non objective marker because each country has a different criteria for what is considered an infant. When a 25 week baby is born in the US we try to save it. If it dies it goes against our infant mortality, whereas in other countries if a baby is born that young or too small even and dies it is cracked up to spontaneous abortion and not counted. Until everyone follows the same standards of what is considered a life then this statistic is meaningless.

Example 2: Life Expectancy should not be used as a marker when there are so many factors that are not affected by healthcare at all. For example, we have higher rates of murder in our country. If someone is murdered in their teens then this drags down our life expectancy. Should we really judge our healthcare system based on a higher rate of murder? This doesn't even take into account obesity, smoking, no exercise, counting prematurely born babies, etc. Healthcare issues aside, there is no way to compare life expectancy because not surprisingly French and American cultures are very different!

[real person from the real world]

I would be interested in knowing where JOHN got his "facts" about the inclusion of factors that skew the statistics people are constantly citing. As one of the unlucky 15%, I would like to know, not that this should invalidate Lafayette's point that Education/training and Health Care should be looked upon as public services. A healthy and well educated work force is better able to compete, so they should be given a serious look. Problem, in my opinion, is that there are too many "rent seekers" in this country.

[John]

Do I really have to go and quote academic papers for you to believe this? Unfortunately I do not have time right now, but I can post this entry from wikipedia which although can be inaccurate usually is pretty close.

"The exclusion of any high-risk infants from the denominator or numerator in reported IMRs can be problematic for comparisons. The United States counts many infant births as live which other countries do not and therefore usually appears to have a much higher rate of infant mortality than similar countries. The US counts an infant exhibiting any sign of life as alive, no matter the month of gestation or the size, but other countries differ in these practices. For example, in Germany and Austria, fetal weight must reach one pound to be counted as a live birth, while in some other countries, including Switzerland, the baby must be at least 12 inches long. Both Belgium and France report babies as born lifeless if they are less than 26 weeks' gestation.[2]"

If I have time I will find the scholarly article. But, as someone who is actually in the medical field and has studied statistics you might just want to believe me.

[John]

In addition, there is also an incentive to count your stillborn baby as a infant death for tax purposes in the United States. Who knows how issues like this can affect the infant mortality rate. This is taken from the Internal Revenue Service (IRS) home web page.

8.1 Earned Income Tax Credit: Qualifying Child Rules

"My child was born and only lived 40 minutes. Can she be used as a qualifying child when figuring the earned income credit and the child tax credit?

If your child was born alive and died during the same year, and the exemption tests are met, you can take the full exemption. This is true even if the child lived only for a moment. Whether your child was born alive depends on state or local law. There must be proof of a live birth shown by an official document such as a birth certificate. Under these circumstances, if you do not have a social security number for the child, you may attach a copy of the child's birth certificate instead and enter "DIED" in column 2 of line 6c of the Form 1040 (PDF) or Form 1040A (PDF).

Normally, to be qualifying child and meet the residency test, your child must have lived with you for more than half of the tax year. For earned income credit purposes, if your child was not alive for more than half of the year, the year, the child is considered to meet the test as if the child lived with you for the entire time he or she was alive during the year. The earned income credit generally requires that you provide a valid social security number for your qualifying child. If you meet all the other requirements to claim this credit and your child was born and died in the same year, you will not be required to provide a social security number for that child. Instead, you may enter "DIED" on line 4 of Form 1040, Schedule EIC (PDF) Earned Income Credit, and attach a copy of the child's birth certificate.

If you have determine that you are eligible to claim your child's exemption, you may also be eligible to claim the child tax credit. Please refer to the Form 1040 Instructions or Form 1040A Instructions for the Child Tax Credit. The referenced pages will explain who qualifies for this credit and how to calculate it.

References:

* Publication 501, Exemptions, Standard Deduction, and Filing Information
* Publication 596, Earned Income Credit
* Form 1040 Instructions
* Form 1040A Instructions
* Tax Topic 601, Earned Income Credit
* Tax Topic 606, Child Tax Credits

says...

Here is a link to the economist.com that explains the stats a little further...

http://www.economist.com/blogs/freeexchange/2007/03/infant_mortality.cfm

[John]

These are stats I KNOW you cannot take at face value:

Infant Mortality Rate
Life Expectancy
47 million uninsured (Don't even get me started on this one)
I can't think of any more at the moment. For example, how many people making over 60K are on that list, how about 75k?)

Sorry I killed the thread with what people DON'T WANT TO HEAR.

[Lafayette]

John: I am against turning the whole system over to the government though.

Explain why.

When market mechanism don't do the job, because the profit incentive is incapable of assuring that services are accessible by the greatest number possible, what alternative is there other than a Public Service?

Why do you think that (city, state, national) governments exist? You would have private enterprise provide the local security of policing (in fact, it does in some circumstance). You would have private enterprise provide the defense of the nation? You would have private enterprise provide fire protection?

The issue is a matter of utility. How can the most good be done for the most people? Free markets offer services that meet a great many of our needs. But, evidently, not all of them.

There is nothing inherently wrong in the profit incentive to rationalize the allocation of resources necessary to meet a desired need. But, it is folly to think that profit-motivated private enterprise is the only way to do so -- particularly in markets where the supply side is constrained by limited resources at high cost.

And, when markets don't meet satisfactorily the common need, citizens have every reason to expect the government to do what markets cannot seem to accomplish. Health Care in America is a glaring example just waiting for such a solution.

Europe is full of examples where public Health Care services work in alliance with its private counterpart to provide a strategic service to the community as a whole.

Which is why, in the World Health Organization classification of worldwide Health Care systems, European countries form the overwhelming proportion of those in the top fifteen.

[Lafayette]

LG: On a more general note, for human basic needs like housing, energy, transporation and health I think that if you compare various country systems performance the market-or-death camp fares quite badly against the state-organized camp.

Having lived in Europe for a great many years, I have seen the proliferation of "public services" lead to profligate spending by the states -- the consequence of which has been state indebtedness and economic paralysis.

There are certain sectors, well-chosen, well-targeted, wherein the state can and should provide the initiative. You mention a couple of them, including transportation. (The US is a nation ideal for a long-distance high-speed rail transport network, which apparently it is incapable of doing. Even China is waking up to this opportunity, and Europe is selling its high-speed train technology there.)

I am less sure that energy is an area where the state need get involved. In France, its decision to embark upon a program to generate electricity by means of nuclear technology is a glowing success. But, were it not for Three-Mile Island, US industry would have provided a similar accomplishment. (The main difference is that coal supplies in the US are more abundant than in France, which is a supply-side contingency.)

As regards housing, I agree that each individual has a basic right to shelter. The state should be involved in providing that service ... but not for an eternity. Public housing must only be a stepping-stone to a person's ability to access his/her own residential property. (Much public housing in France is in a disastrous condition due to overuse.)

Whatever the various alternatives, it all comes down to balancing state intervention with private sector offerings. There must be a harmony between the two.

Bu "cradle to grave" public assistance, as was the principle intent of many governments in Europe, is as dead as a doornail -- and well it should be.

The paradigm has changed -- Europe no longer has the protection of its tarif-barrier cocoon that permitted governments to think that burgeoning economies could provide endlessly large public assistance programs.

Those days are gone forever.

[Lafayette]

PD: That's because the French share Americans' distaste for restrictions on patient choice and they insist on autonomous private practitioners rather than a British-style national health service, which the French dismiss as "socialized medicine."

Bollocks. The French do not "dismiss" socialized medicine; they benefit from it.

Dutton is just another wordmonger who has tripped over the word "socialized", which has a negative connotation in America.

Yes, in France, you get to choose amongst doctors. But, frankly, most people shop around till they find a GP that suits them. Unfortunately, it has also lead to what the French call the Imaginary Malady (after a play by Moliere), that is, people who traipse around from doctor to doctor to have treated a psychosomatic illness. Of course, doctors oblige, because they get their fees for the visit.

In France, the GP makes the preliminary decision regarding further analysis for diagnosis. The patient is free, however, to take any "conventioned medical pratitioner". The word "conventioned" means that the doctor has signed onto the agreement to accept state-imposed fees for their services.

This is "socialized medicine" in France. Most "conventioned" doctors in France do not drive Mercs. Those who are not "conventioned" remain as private practitioners and may ask whatever is the going rate. They earn a fairly good living, but nowhere near that of the "conventioned" practitioner. Neither are the latter as poor as a church mouse.

What this disposition allows is that doctors in rural communities -- or in those communities where private practitioners would not likely go because of low income levels -- are allowed to practice and earn a decent salary.

"Socialized medicine" is all about ACCESSIBILITY to the largest number, that is, the utility of the Health Care public service. It is the reason that France (and the other European countries, including the UK) are in the top fifteen countries worldwide in the WHO classification.

It finds a political context only in the fact that most European citizens prefer that Health Care be a Public Service available to the largest number of people. (Really "Marxian" thinking, that ...) Consequently, politicians are reluctant to finagle with it.

Of course, the bottom-line (sic!) of this is that doctors in Europe that adhere to public service pricing conventions do not cost and arm and leg - which must bother the hell out of the AMA. The AMA wants Americans to go to "unconventioned" doctors thereby assuring high-cost practitioners specifically and exorbitant Health Care in general. That's why they are a lobby.

And, which is why one reads the sort of tedious comment cited above that distorts the reality of equitable Health Care. (Makes one wonder how much Dutton received to plant that piece.)

[Cyrille]

A nice side effect of government-run healthcare is that the government then has a direct financial incentive to promote preventive behaviour. That includes healthy food at school cantines...

[John]

People that fear the AMA right now (with no power whatsoever) will have something to be afraid about if socialized medicine comes about because that means Doctors will be allowed to unionize.

[anne]

Your comments are perfectly idiotic, as I suspected at once and understood soon after, but go right on making idiotic comments. Add in a few capitals and don't get me started-s for effect, since that helps.

[anne]

"People that fear the AMA right now (with no power whatsoever) will have something to be afraid about if socialized medicine comes about because that means Doctors will be allowed to unionize."

Typical idiocy, only the latest however.

[anne]

Remember by the way because remembering such things is important, the rise in infant mortality through the South is really not happening if we knew how to count properly only of course it is happening but likely France would not notice what happens in Mississippi.

says...

http://www.nytimes.com/2007/08/12/opinion/12sun1.html?hp

August 12, 2007

World's Best Medical Care?

Many Americans are under the delusion that we have "the best health care system in the world," as President Bush sees it, or provide the "best medical care in the world," as Rudolph Giuliani declared last week. That may be true at many top medical centers. But the disturbing truth is that this country lags well behind other advanced nations in delivering timely and effective care.

Michael Moore struck a nerve in his new documentary, "Sicko," when he extolled the virtues of the government-run health care systems in France, England, Canada and even Cuba while deploring the failures of the largely private insurance system in this country. There is no question that Mr. Moore overstated his case by making foreign systems look almost flawless. But there is a growing body of evidence that, by an array of pertinent yardsticks, the United States is a laggard not a leader in providing good medical care.

Seven years ago, the World Health Organization made the first major effort to rank the health systems of 191 nations. France and Italy took the top two spots; the United States was a dismal 37th. More recently, the highly regarded Commonwealth Fund has pioneered in comparing the United States with other advanced nations through surveys of patients and doctors and analysis of other data. Its latest report, issued in May, ranked the United States last or next-to-last compared with five other nations — Australia, Canada, Germany, New Zealand and the United Kingdom — on most measures of performance, including quality of care and access to it. Other comparative studies also put the United States in a relatively bad light.

Insurance coverage. All other major industrialized nations provide universal health coverage, and most of them have comprehensive benefit packages with no cost-sharing by the patients. The United States, to its shame, has some 45 million people without health insurance and many more millions who have poor coverage. Although the president has blithely said that these people can always get treatment in an emergency room, many studies have shown that people without insurance postpone treatment until a minor illness becomes worse, harming their own health and imposing greater costs.

Access. Citizens abroad often face long waits before they can get to see a specialist or undergo elective surgery. Americans typically get prompter attention, although Germany does better. The real barriers here are the costs facing low-income people without insurance or with skimpy coverage. But even Americans with above-average incomes find it more difficult than their counterparts abroad to get care on nights or weekends without going to an emergency room, and many report having to wait six days or more for an appointment with their own doctors.

Fairness. The United States ranks dead last on almost all measures of equity because we have the greatest disparity in the quality of care given to richer and poorer citizens. Americans with below-average incomes are much less likely than their counterparts in other industrialized nations to see a doctor when sick, to fill prescriptions or to get needed tests and follow-up care.

Healthy lives. We have known for years that America has a high infant mortality rate, so it is no surprise that we rank last among 23 nations by that yardstick. But the problem is much broader. We rank near the bottom in healthy life expectancy at age 60, and 15th among 19 countries in deaths from a wide range of illnesses that would not have been fatal if treated with timely and effective care. The good news is that we have done a better job than other industrialized nations in reducing smoking. The bad news is that our obesity epidemic is the worst in the world.

Quality. In a comparison with five other countries, the Commonwealth Fund ranked the United States first in providing the "right care" for a given condition as defined by standard clinical guidelines and gave it especially high marks for preventive care, like Pap smears and mammograms to detect early-stage cancers, and blood tests and cholesterol checks for hypertensive patients. But we scored poorly in coordinating the care of chronically ill patients, in protecting the safety of patients, and in meeting their needs and preferences, which drove our overall quality rating down to last place. American doctors and hospitals kill patients through surgical and medical mistakes more often than their counterparts in other industrialized nations.

Life and death. In a comparison of five countries, the United States had the best survival rate for breast cancer, second best for cervical cancer and childhood leukemia, worst for kidney transplants, and almost-worst for liver transplants and colorectal cancer. In an eight-country comparison, the United States ranked last in years of potential life lost to circulatory diseases, respiratory diseases and diabetes and had the second highest death rate from bronchitis, asthma and emphysema. Although several factors can affect these results, it seems likely that the quality of care delivered was a significant contributor....

[anne]

Sorry, the post of the New York Times editorial was mine.

[Soothsayer]

To Anne:

None of your posts make any sense. I think I understand what you are trying to say, but I cannot be completely certain. Is English your first language?

Also, thank you for posting an article from the largest pro universal healthcare newspaper in the country. Why would I trust an article that starts with this sentence:

"Many Americans are under the delusion that we have "the best health care system in the world," as President Bush sees it, or provide the "best medical care in the world," as Rudolph Giuliani declared last week."

Does this come form the opinion column?

[Lafayette]

sooth: Why would I trust an article that starts with this sentence: "Many Americans are under the delusion that we have "the best health care system in the world," as President Bush sees it, or provide the "best medical care in the world," as Rudolph Giuliani declared last week."

Because its true? The above delusions exist.

Now, tell us why YOU don't see the lie.

Just arrive to this forum? We've been discussing this for at least six months, including factual evidence.

[John]

I do believe my healthcare is the best in the world. Everyone in our country just doesn't get it. If you would control factors such as obesity, smoking, exercise, etc. and then compare the people who receive healthcare in our country to those who receive healthcare in other countries we would be superior to them. That is why I don't think the whole system should be turned upside down just becuase we have people who are dragging our numbers down. Instead, the government should try to expand and properly fund programs like medicaid to include the people who don't get help into our system that is superior in delivering healthcare, but not just to everybody.

says...

This is why requiring everyone to buy insurance is a great way to go about bringing healthcare to everyone. People will not be able to hide behind the excuse of not being able to afford health insurance when they can afford late model cars, cell phones, nice watches, Maui vacations, big houses, cable television with 30 movie channels, etc. If you spent a good stint in the ER you would be amazed at the people who don't have health insurance.

So then after everyone who can really afford health insurance has bought it those who can't afford health insurance will be subsidized through a properly funded medicaid program. One of the problems that we face with the 47 million uninsured is that millions qualify for medicaid, but they don't know how to sign up or that it is available to them. Of course, medicaid right now is joke considering they don't even cover the cost of seeing a patient to break even let along make money for providers so basically it is community service. That is why medicaid would have to strengthened for this plan to succeed.

My belief is that we have the best healthcare in the world. It is just not available to everyone though. So instead of trying to topple the whole system, we need to help bring these people into the system. Now, how is this not reasonable.

[BJ Feng]

Don't you think that artificially reducing doctors' incomes will have a negative impact on the number of talented people who choose to be doctors? To become a specialist, it takes, what, six years of training? I know that most doctors are several hundred thousand dollars in debt when they first start out. I'm sorry, but the quality of our doctors will be affected if we reduce their incomes. We could be forced to import doctors from Pakistan or India as the British do, or suffer shortages. We could subsidize their education, but that would be another cost, and capping the cost of education would reduce the quality of what they learn.

If you want a proposal, how about this one? Right now, most people can just walk into their county medical center and get free treatment. Governments could increase funding to more of these centers and perhaps even open up more. Those who get treatment there will understand that they will get treatment from doctors doing residency if possible, and will not get the same perks of private medical service, such as extended hospital stays. However it will be free.

Years ago two friends of mine had parallel experiences. Both tore their ACLs while playing basketball. One, Steve, had insurance from Kaiser Permanente, while the other, Phil, had to go to USC County Medical to get his operation. Steve scheduled his operation, and was able to stay in the hospital for a day. As for Phil, he also scheduled an operation that was successful, but of seemingly poorer quality. A few hours after the operation, he was woken up and told to leave the hospital, even though he was still groggy from the drugs and wanted to sleep. Phil received worse treatment, but it was free and both can walk, and run fine. This kind of system would not be as expensive as the ones being proposed right now and would give everyone access to health care.

John says...

Cardiology = 4 year college degree + 4 years medical school + 3 year internal medicine (34k salary) + 3 general cardiolog